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Hard to Swallow

Jeffrey Driver, JD, MBA | October 1, 2004
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The Case

An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, whose speech was normal before surgery, now had slurred speech and choked on thin liquids. The neurologist recommended a swallowing study.

A speech pathologist evaluated the patient and found him to be at high risk for aspiration. On the consultation form, she recommended that the patient be made NPO. She didn't think the recommendation was important enough to "bother" the physician, and recorded it only on the consultation form. In keeping with standard practice at the hospital, speech pathologists, respiratory therapists, and physical therapists write their notes in a special section of the chart, not in the core daily progress notes area, which is the part of the chart that all physicians read. The physician did not see the form, and the patient continued to receive thickened liquids. Two days later, the patient suddenly aspirated, arrested, and died.

The hospital investigates all critical incidents through the Quality Management Department and the Vice President of Medical Affairs. This particular case was reviewed within an hour of the patient's death. Subsequently, the VP of Medical Affairs submitted a protocol to the medical staff executive committee concerning swallowing evaluations. This protocol, now in effect, permits the speech pathologist to write the order to make the patient NPO if the bedside swallowing evaluation is suspicious for the risk of aspiration. Hospital personnel felt that physicians would accede to speech pathologists' recommendations to keep a patient NPO (for aspiration risk), and that it was safer to have the physicians "pre-authorize" an NPO order than risk a repeat of this scenario by waiting for a physician's order.

The Commentary

The critical error in this case, often classified by risk managers broadly as "a failure to treat," has deeper roots in the failure of communication, both written and verbal. Some studies cite practitioner communication skills as a factor in malpractice.(1,2) Furthermore, the tragic outcome in this case might have been avoided if protective actions were implemented pending the completion of the diagnostic evaluation (ie, if the patient were made NPO pending the outcome of the swallowing evaluation).

Although its main purpose is to document patient care, the patient's medical record is also a tool for collecting, storing, and processing information. Moreover, the record can be a conduit of communication between the physician and other members of the health care team.(3) However, it is by no means the perfect or only tool for communication. Based on work in adult learning (4), risk managers recommend promoting effective communication by transmitting information repetitively and by way of several different modalities. These modalities include written (eg, letters written by consultants to referring clinicians), person-to-person verbal (eg, telephoning the referring clinician after finishing a consultation), and red flag signals of newly posted critical information (eg, the notes sometimes left by nurses on the front of charts to draw the attention of treating physicians to a particularly important recent lab result or problem with an order).

Risk managers analyze medical records while performing root cause analysis and/or medico-legal review to determine what events and contributing factors led to a particular medical injury or adverse event. Ultimately, these analyses serve two purposes: they set patient-protective controls to reduce the chances that an accident will recur, and they support preparation for potential litigation. Surprisingly often, these retrospective reviews reveal subtle (or not so subtle, as in this case) medical information, which, had it been detected by the clinicians at the time, could have led to follow-up actions to mitigate or avert an adverse patient outcome.

How can we be sure that important patient information is communicated and received? First, clinicians must identify the subset of patient-related data (lab results, diagnostic evaluation, etc.) that represents critical information. A fail-safe mechanism also must be in place to communicate and receive critical medical information in a timely and effective manner. While several methods can facilitate the communication and receipt of critical information, one-to-one verbal communication should never be replaced, nor should sole reliance be placed on written communication (because the latter is not fail-safe). Critical medical information must be communicated verbally, and receipt of such information should be documented in the medical record. In this case, since the patient was receiving a normal diet, it would have been appropriate for the speech therapist to communicate the need to change the diet orders in a more timely and direct fashion than solely writing in the patient's medical record (eg, by phoning the attending physician). However, the responsibility hardly falls on the speech therapist alone. The neurologist who requested the consult should either have been watching for the results or advised the primary team to do the same. At a deeper level, physicians need to make sure they do not contribute to a culture in which non-physician providers avoid direct communication for fear of "bothering the doctor." The speech therapist's decision not to communicate directly may reflect past experiences in which she sensed exasperation or impatience on the part of a physician she had paged with similar information.

The medical record plays an important role in providing a back-up to one-to-one verbal communication. The problem, as illustrated in this case, is that sometimes information in the medical record is not promptly given to those clinicians who should act on it. This delay occurs primarily because medical records are voluminous and often organized in ways that promote segmentation of information. How the medical record was organized in this case is not unusual, nor is the illusion that certain parts of the record do not require review by all clinicians.

A number of methods have been implemented to simplify medical record keeping and thereby highlight critical information. Chart flags, color-coded consult notes, follow-up checklists, and multidisciplinary problem lists have all been used to enhance communication and receipt of critical medical information. Also, in combination with these methods, nurses (and sometimes other medical care providers) may use a process of "charting by exception," which means that under specific written protocol, certain medical information can be assumed because the patient observations fall within a safe range as dictated by the protocol.(5,6) This effectively reduces the volume of entries in the medical record, thus theoretically leaving a medical record filled with only the most relevant medical information. In addition, a number of innovations in medical record keeping such as computerized physician order entry (CPOE) and the electronic medical record (EMR) create safety mechanisms to assure that important communication occurs. These include automatic digital paging (7) and e-mail notification (8,9) as well as warning screens in CPOE and the CMR that alert clinicians to critical information. Speech recognition systems and electronic word-entry systems are being developed to recognize words and values, alone or in combination, that trigger an electronic alert to clinicians. (For a full list of medical record best practices, obtain the practice brief published by the American Health Information Management Association.[10]) Finally, frequent multidisciplinary patient care rounds (11), Crew Resource Training (12), and Patient Safety Rounds (13) may help enhance clinical communication and thus reduce medical accidents due to failed communication, such as the one in this case.

Finally, let's consider some of the specifics of this case. Risk managers are charged with finding the root cause of medical accidents, near misses, and accidents-waiting-to-happen, and putting steps into place to reduce the likelihood of accidents, thus protecting patients from medical injury. In addition, risk managers are duty-bound not only to protect patients from injury, but also to protect clinicians and the organizations they work in from legal liability. In this case, liability could be attributed to the physicians, the speech therapist, and the nurses caring for the patient. All of them failed to communicate and/or receive critical medical information, and their failure led to the patient's aspiration.

The hospital where this case occurred has suggested an organizational solution to the problem. Having a standard order to allow speech therapists to place patients on NPO status when necessary is sound risk management because it provides a high level of patient protection. This effectively reduces the possibility of aspiration from the time of the physician's order to the time the diagnostic test results or consult is reviewed and an order for NPO status is continued or discontinued by the physician. Less clear, however, is whether this hospital has addressed the underlying communication problems that led to this accident—problems that could recur in another situation.

Medical errors and accidents due to communication mishaps are complex and multifaceted. Hospitals and clinicians should be cautious of quick fixes or reliance on a single prevention technique. Any one of the methods used alone (including those suggested here) might fail. Reason has described improving safety as akin to fighting mosquitoes: we have to drain the swamp, rather than just swat at individual mosquitoes.(14) This means that we need to be careful that, after an accident investigation or root-cause analysis, we don't design protocols that prevent only the specific error from happening again. In this case, an NPO order was the problem, but the root cause analysis revealed general problems with communication. The chance that another patient will die due to lack of a timely NPO order is relatively small. However, the chance that problems in inter-professional communication will cause other adverse events is high. The institution needs to make sure it does something about the latter, not just the former.

Truly, the best practice is to undertake comprehensive risk assessment (15) by understanding communication processes, learning where they are subject to fail, and identifying the results of each failure. Only then can multiple and redundant solutions be implemented to address those critical points. Promoting fail-safe communication of important medical information can reduce patient harm and medical liability.

Jeffrey Driver, JD, MBA Chief Risk Officer Stanford University Medical Center


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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